CASE REPORT © 2019 Polish Dental Association

IATROGENIC DISLOCATION OF THE LOWER WISDOM

TOOTH TO THE PERIMANDIBULAR SPACE – A CASE REPORT

Miłosz Ambicki, Bogumił Lewandowski

Department of Maxillo-Facial Surgery, F. Chopin Clinical Provincial Hospital in Rzeszow, Poland

ABSTRAC T
Iatrogenic dislocation of the lower wisdom tooth to the bottom of the oral cavity and neck is a rare complication
that may occur during surgical extraction, usually causing inflammation and abscesses, and therefore it requires
specialist treatment in a hospital in the Department of Maxillo-Facial Surgery. The case described in this paper
required surgical removal of  the  displaced tooth and evacuation of  the  abscess from the  extraoral approach.
The patient had uneventful perioperative course, no postoperative complications were observed, and the healing
proceeded in a normal way. During three outpatient follow-ups carried out at intervals of one month, no abnor-
malities in healing were found.

Key words: wisdom teeth, surgical extractions of third molars, accidental iatrogenic complication, treatment
of complications, displaced tooth.

J Stoma 2019; 72, 3: 142–146

DOI: https://doi.org/10.5114/jos.2019.87535

INTRODUCTION of the tooth or its fragment to the perimaxillary tissues

Extractions of  retained wisdom teeth are common
procedures in dental practice as well as in dental and
maxillo-facial surgery worldwide. Due to the  much-
delayed development of the lower third molars in rela-
tion to the remaining teeth, they are the most common
retained teeth which is often an indication for their surgi-
cal extraction. These treatments are usually elective after
proper examination of the patient, which consists of as-
sessment of the teeth positions on the base of pantomo-
graphic X-ray and planning of the operating method and
technique. Postoperative care is also important [1, 8, 15].
During and after the surgical extraction of the wisdom
tooth, different complications may occur, both general
and local. The list of possible complications is very long.
Among these complications, iatrogenic displacement
Bimonthly Vol. 71
and anatomical structures is definitely worth mention-
ing. This includes: dislocation of  the  tooth to the  max-
illary sinus, to the mandibular canal, and to the tissues
of  the  bottom of  the  oral cavity and the  cheek  [3, 4].
One of the most frequently occurring complications in
this group is the displacement of the upper third molar
or its fragment into the  maxillary sinus  [14]. Acciden-
tal insertion of the lower wisdom tooth or its fragment
into the  tissues of  the  mouth and neck, i.e. sublingual,
submandibular, or pterygomandibular space, is rare-
ly presented in the  literature, and then usually as case
studies [2, 5, 12, 13]. The cortical bone plate that covers
the roots of the lower molars from the lingual side is very
thin. Its partial lack in the area of the third molars may
be favourable to different complications and dislocations
of the tooth to the surrounding soft tissues [6, 7, 9-11].
Issue 3 May-June 2018 p. 249-314 ISSN 0011-4553

Address for correspondence: Miłosz Ambicki, Department

of Maxillo-Facial Surgery, F. Chopin Clinical Provincial Hospital in Rzeszow,
O F F I C I A L J O U R N A L O F T H E P O L I S H D E N TA L A S S O C I AT I O N O R G A N P O L S K I E G O TO WA R Z Y S T WA S TO M ATO L O G I C Z N E G O
Poland, e-mail: milosz.ambicki@gmail.com
Received: 12.04.2019 • Accepted: 05.08.2019 • Published: 08.08.2019

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Iatrogenic dislocation of the lower wisdom tooth

This paper presents a  rarely described complica- On the seventh day after the procedure, the patient
tion that occurred in a  patient during the  extraction reported for follow-up. A slight swelling of the operated
of the lower left wisdom tooth (tooth 38) and consisted area and gradually disappearing lock-jaw without pain
of its accidental insertion to surrounding perimandibu- continued. The patient did not become feverish. Clinical
lar tissues of the bottom of the oral cavity and the sub- examination showed normal healing without symptoms
mandibular space. of inflammatory infiltration in the oral cavity and peri-
mandibular tissues. Antibiotic therapy was continued.
A follow-up in 10 days was recommended, at which
CASE PRESENTATION the  patient did not report any disturbing symptoms.
The patient, aged 23 years, reported to the  Clinic Swelling and lock-jaw subsided. The wound healed well.
of Maxillo-Facial Surgery, F. Chopin Clinical Provincial
Hospital in Rzeszow to treat complications after un- DISCUSSION
successful extraction of  a  lower wisdom tooth caused
by insertion of tooth 38 into the tissues of the bottom Only a few publications in the literature concern ac-
of the oral cavity. Medical history revealed that the in- cidental insertion of the wisdom tooth or its parts into
dications for extraction were occasional symptoms the perimandibular tissues as a complication during re-
and inflammation in the  area of  the  partially erupted moval of wisdom teeth [2, 5, 6, 10, 11, 12-14]. Accord-
lower wisdom tooth on the left. Ailments subsided af- ing to Brauer’s report this complication is estimated at
ter conservative local treatment and antibiotic therapy. about 1%; however, in the literature there is no detailed
Tooth 38 was qualified for extraction after analysing research on this subject  [3]. The  most common cause
the pantomographic X-ray with the consent of the pa- is iatrogenic fracture or damage of  the  cortical layer
tient (Figure 1). During the removal of tooth 38 technical of the alveolar bone in the region of the extracted wis-
difficulties occurred. As a result of the surgery the tooth dom tooth due to use of excessive force or improper sur-
was dislocated to the perimandibular tissues. The pro- gical technique [2, 11, 13]. Unskilful use of the straight
cedure and further attempts to remove the tooth were tooth elevator or luxator may cause uncontrolled, ac-
abandoned. Immediately after the surgery the physician cidental displacement of  the  tooth beyond the  alveo-
performing the  procedure administered an  antibiotic lus  [4, 8, 15]. Significant risk factors for complications
(clindamycin) in a dose of 3 × 300 mg and took a pano­
ramic radiograph (Figure 2). On the day after the pro-
cedure gradually increasing pain, lock-jaw, swelling
of the submandibular region on the left, and then diffi-
culty in swallowing occurred. An additional cone beam
computed tomography (CBCT) (Figures 3 and 4) exam-
ination was performed for more accurate diagnosis, and
the patient was urgently referred to the Clinic of Maxil-
lofacial Surgery, F. Chopin Clinical Provincial Hospital
in Rzeszow. On admission to the clinic, the patient was
found to have hard, tender, board-like, and non-mov-
able swelling in the  left submandibular area. She also
reported increasing difficulties in swallowing both sol-
id and liquid food and difficulty in opening the jaws at
about 1 cm. A  continuation of  antibiotic therapy was FIGURE 1. Before extraction of tooth 38
ordered, along with analgesics and anti-oedema med-
ication. On the  basis of  a  clinical examination and
X-ray imaging, the patient was qualified and prepared
for the surgical extraction of the displaced tooth 38 un-
der general anaesthesia. The abscess with the presence
of the tooth was localised from the extra-oral approach,
in the  left submandibular region. The  abscess was
drained and then the tooth was extra-oral, which took
place on the inside, on the lingual side of the mandible
(Figures 5 and 6). After the operation passive drainage
was used for 24 hours. On the third day after the pro-
cedure, the patient was discharged home in good local
and general condition with a recommendation to con- FIGURE 2. After unsuccessful extraction of tooth 38.
tinue antibiotic therapy. Displaced tooth 38 can be seen

J Stoma 2019, 72, 3 143

Miłosz Ambicki, Bogumił Lewandowski
FIGURE 3. Cone beam computed tomography scan.
Displaced tooth 38 can be seen
FIGURE 5. Extra-oral approach in left submandibular re-
gion
are: the  anatomical structure of  the  mandible in this
area and defects of  the  cortical layer from the  lingual
side of the alveolar bone in the mandible, distal and lin-
gual location of the lower wisdom tooth, concavity and
blocking of roots of the retained tooth, and the patient’s
age. The reason for the presence of “cavities” in the cor-
tical lingual layer of  the  mandible may be idiopathic
or iatrogenic, and can be associated with inflammato-
ry processes or the presence of cysts in this area. Idio-
pathic disruption of bone continuity is usually small. In
this site bone offers weaker resistance when removing
the  tooth, predisposing to its displacement in this di-
rection [15].
Surgical removal of the lower wisdom tooth involves
using lesser or greater strength, sharp surgical instru-
ments, and rotary tools, which is why one cannot omit
the  iatrogenic factor associated with the  improper use
of  surgical instruments. Often lack of  experience and
intuition, inappropriate technique, excessive strength,
as well as the wrong point of its application can lead to
fracture of  the  alveolus or fracture of  the  mandibular
body, which facilitates the displacement of the extracted
144
FIGURE 4. Cone beam computed tomography scan.
Alveolus 38
FIGURE 6. Extra-oral extraction of dislocated tooth 38 in
left submandibular region
tooth [2, 13]. In some cases, there is a need for osteotomy
on the lingual side to expose the tooth crown. The me-
dial or lingual position of a retained wisdom tooth re-
quires cutting off the tooth crown from the root. The use
of rotational tools carries the risk of damaging them and
breaking or piercing the bone. Wisdom teeth in the dis-
tal lingual position with abnormalities in the anatomi-
cal structure of the root and the previously mentioned
discrepancies in the anatomical structure of the surgical
site constitute an additional risk of postoperative com-
plications [4, 8, 15].
Before the  surgery is planned a  physical examina-
tion and interview should be carefully performed. It
should also be extended with the  necessary radiologi-
cal diagnostics to assess possible difficulties resulting
from the position of the retained tooth and its relation
to the lower alveolar nerve canal and adjacent teeth in
the aspect of possible complications. In some cases, in
addition to the  pantomographic X-ray, it is advisable
to perform a  CBCT examination, which additionally
presents the  projection of  the  retained tooth in three
dimensions [7]. It allows the assessment of the position
Journal of Stomatology * http://www.jstoma.com
Iatrogenic dislocation of the lower wisdom tooth
of the tooth in relation to important anatomical struc-
tures more accurately than via panoramic radiograph.
When starting the  surgical procedure of  removal
of  the  wisdom tooth the  patient should be informed
about the method and technique of the procedure, po-
tential consequences, and postoperative complications
that may occur. In the case of complications the patient
should be informed about them immediately after they
took place.
The literature describes a number of surgical meth-
ods allowing the  procedure to be performed efficient-
ly, to rule out potential postoperative complications. In
some cases, it is advisable to cut and separate the crown
of the tooth. Some authors recommend putting pressure
on the lingual margin of the alveolar region of the man-
dible while elevating the tooth. This prevents its displace-
ment towards the tongue and the bottom of the mouth
and reduces the likelihood of breaking the lingual lam-
ina  [1, 8]. Another method is to place a  raspatory or
a  retractor between the  detached mucoperiosteal flap
and the  bone of  the  alveolar part of  the  mandible on
the lingual side optimally convex of the tool to the tooth
being removed  [8]. This procedure prevents the  tooth
from moving towards the bottom of the oral cavity, and
enables the tooth an extraction tool to be used outside
the alveolus. In a situation in which a complication oc-
curs in the form of a tooth or a part of it being inserted
into the tissues of the bottom of the oral cavity, the au-
thors recommend that dentists with no surgical expe-
rience refrain from attempting to remove the  already
dislocated tooth.
These attempts are often difficult and lead to fur-
ther displacement of the tooth into the tissues. During
the  preparation period the  treatment as well as possi-
ble complications and consequences of  the  procedure
should be presented to the  patient. The  patient should
be informed about the occurrence of complications and
then referred to the reference centre for specialist treat-
ment. A  referral to a  reference centre should contain
relevant information about the  tooth being extracted,
e.g. about the approximate size of its fragment, the cir-
cumstances of the complications, and radiological doc-
umentation [1, 15]. Referral should be in urgent mode.
If the delay cannot be avoided, e.g. due to the consider-
able distance between medical offices, the dentist should
dress the wound with a surgical dressing and introduce
antibiotic therapy.
The data from the  literature is not consistent as to
the time and urgency of extracting the tooth displaced
into the  surrounding tissues. Some authors suggest
postponement of surgery for up to several weeks. Post-
ponement of the procedure is aimed at achieving fibro-
sis of tissues surrounding the displaced tooth or its frag-
ment, which can stabilise its position and in the future
facilitate extraction during surgery  [13]. In that case
strict control should be continued because the inserted
material is treated as a foreign body that can move deep-
J Stoma 2019, 72, 3
er into the anatomical structures and impede its subse-
quent extraction [6]. Postponing surgery can often lead
to the formation of an abscess and cause not only local
complications like pain, swelling, lock-jaw, or dysphagia
but also general inflammatory reaction [3, 7, 9]. Kose et
al. [6] suggest removal of the dislocated tooth as soon as
it is possible.
Aznar-Arasa et al. believe that the treatment of a tooth
or a part of it that has been displaced depends on its size
and location [2]. If the fragment is smaller than 5 mm,
patients usually do not report any complaints, and there
are no clinical symptoms. The authors described a case
of  a  patient with a  fragment of  a  root dislocated into
the perimaxillary tissues. During the five-year follow-up
no clinical symptoms in the  form of  inflammation or
other similar reaction occurred. In these situations, no
surgical treatment is required. The displacement of larg-
er fragments (> 5 mm) or the  whole tooth usually re-
sult in fast proceeding inflammatory complications and
the need for surgical treatment. In the author’s opinion
treatment under general anaesthesia or local anaesthe-
sia with intravenous sedation should be performed. This
avoids the  patient’s involuntary movements that make
the  procedure difficult and increase the  risk of  further
complications [8, 15].
The surgical approach in each case should be planned
individually, depending on the location of the tooth or
its fragment  [1, 3, 4, 8, 15]. The  most common intra-
oral approach in the  case of  dislocation to the  tissues
of the oral cavity and the surrounding sublingual area is
the incision and mobilisation of the envelope lingual mu-
co-periosteal flap from the mandibular ramus to the pre-
molar area [1, 15]. However, this technique gives limited
access and insight into the tissues of the mouth due to
the mylohyoid muscle, which is located in this area [2,
15]. In the case of dislocating the tooth into the deeper
locations, e.g. to the submandibular region, extraoral or
intraoral approach or both are required [15]. In the de-
scribed case the  decision about the  extra-oral surgical
approach was made on the basis of clinical examination
and assessment of  the  panoramic X-ray and CBCT in
terms of  the  location of  a  displaced tooth in the  sur-
rounding tissues. The patient underwent the procedure
well, and no postoperative complications were observed.
Healing was normal. Three outpatient follow-ups were
performed at monthly intervals, which did not reveal
any abnormalities.
CONCLUSIONS
Complications associated with the  surgical extra-
ction of retained wisdom teeth occur frequently in den-
tal practice, but in many cases they can be prevented by
proper preparation of the patient for the procedure and
evaluation of  the  difficulties resulting from the  clini-
cal-anatomical location of  the  retained tooth. The  rich
145
Miłosz Ambicki, Bogumił Lewandowski

radiological symptomatology of retained lower wisdom

teeth additionally confirms the need for individual plan-
ning of surgeries with regard to possible difficulties, as
well as assessing them according to one’s competence
and training [8, 13].

CONFLICT OF INTEREST
The authors declare no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.

References
1. Asanami S, Kosazaki Y. Expert third molar extractions. Tokyo,
Chicago: Quintessece Pub. Co.; 1990.
2. Aznar-Arasa L, Figueiredo R, Gay-Escoda C. Iatrogenic displace-
ment of lower third molar roots into the sublingual space: report
of 6 cases. J Oral Maxillofac Surg 2012; 70: e107-e115.
3. Brauer HU. Unusual complications associated with third molar
surgery: a systematic review. Quintessence Int 2009; 40: 565-570.
4. Czechowska E, Rydzewska-Lipńska M, Szubert P, Sokalski J.
Complications during the surgical wisdom tooth removal – case
report. Dental Forum 2013; 41: 119-122.
5. I-Yueh H, Chao-Ming C, Sung-Wen C, Chia-Fu Y, Chung-Ho C,
Chun-Min C. Surgical management of  accidentally displaced
mandibular third molar into the pterygomandibular space: a case
report. Kaohsiung J Med Sci 2007; 23: 370-374.
6. Kose I, Koparal M, Gunes N, et al. Displaced lower third molar
tooth into the submandibular space: two case reports. J Nat Sc Biol
Med 2014; 5: 482-484.
7. Lee D, Ishii S, Yakushiji N. Displacement of maxillary third molar
into the lateral pharyngeal space. J Oral Maxillofac Surg 2013; 71:
1653-1657.
8. Peterson LJ, Ellis E, Hupp JR, Tucker MR. Oral and maxillofacial
surgery. Polish Edition: Pogorzelska-Stronczak Z. Lublin: Czelej;
2001.
9. Pippi R, Perfetti G. Lingual displacement of an entire lower third
molar. Report of a case with suggestions for prevention and man-
agement. Minerva Stomatol 2002; 51: 263-266.
10. Satnam SJ, Vidya R, Sachin KR. Intraoral management of displaced
root into submandibular space under local anaesthesia – a case re-
port and review of literature. Saud Dent J 2014; 26: 181-184.
11. Silveira RJ, Garcia RR, Botelho TL, Franco A, Silva RF. Accidental
displacement of third molar into the sublingual space: a case re-
port. J Oral Maxillofac Res 2014; 5: e5.
12. Suer BT, Kocyigit ID, Ortakoglu K. Iatrogenic displacement of im-
pacted mandibular third molar into the pterygomandibular space:
a case report. Oral Health Dent Manag 2014; 13: 179-182.
13. Sufeng Z, Zheng H, Tengyu G, Lanzhu H. Intraoral management
of iatrogenically displaced lower third molar roots in the sublin-
gual space: a report of 2 cases. Int J Clin Exp Med 2015; 8: 19591-
19595.
14. Sverzut CE, Trivellato AE, Lopes LMF, Ferraz EP, Sverzut AT. Ac-
cidental displacement of  impacted maxillary third molar: a  case
report. Braz Dent J 2005; 16: 167-170.
15. Tetsch P, Wagner W. Operacyjne usuwanie zęba mądrości. War-
szawa: Wydawnictwo Medyczne Sanmedica; 1994.

146 Journal of Stomatology * http://www.jstoma.com